Heads Up!

A Soccer Coach's Guide To Concussions.


Heads Up! A Soccer Coach’s Guide to Concussion

By Robert J. Elbin, Anthony P. Kontos and Tracey Couassin

About 300,000 sport-related concussions occur every year in the United States. Although sports such as football, rugby and ice hockey receive more attention for concussion, studies show that soccer players also are at risk. In fact, it estimated that every year in the United States, 6 percent of high school and 5 percent of college soccer players have a concussion. Therefore, it is important for soccer coaches to be able to recognize concussions and their potential effect on players. They should also be aware of the recent development and marketing of protective headgear in soccer, and the effectiveness of such products in reducing concussion.

A concussion can occur when a player’s head directly contacts an opponent, the ball, the goal post or the ground. A concussion also can occur without direct contact when a player’s head comes to an abrupt halt (like a “whiplash”), causing the brain to rebound off or twist inside the skull. This type of concussion has an effect similar to the yolk of an egg crashing up against the inside of the eggshell when shaken; however, the skull’s interior is not smooth like the inside of an eggshell. The resulting forces can damage blood vessels and neurons, resulting in swelling and bleeding in the brain. Unlike an injury such as a sprained ankle, which has a fairly predictable set of progressive and visible symptoms, an injury involving the brain is more complex and less visible than the ankle. In fact, some researchers have begun referring to concussion as the “invisible injury.”

The complexity of the brain and the location of a concussion combine to create a wide variety of symptoms, cognitive impairments and performance difficulties. (Table 1) The signs and symptoms a player experiences following a concussion are influenced by the area of the brain that was affected. For example, a player who goes up for a flick-on header and strikes the back of his head (an area of the brain responsible for vision) on the defending player’s forehead may experience visual symptoms such as blurry or double vision or sensitivity to light.

Researchers have examined these symptoms and cognitive impairments in an attempt to understand and predict recovery from concussion. One symptom that has been associated with concussion is loss of consciousness (LOC), or being “knocked out.” A common misconception is that an athlete must have LOC in order to have a concussion; however, only about 6 to 10 percent of all concussions involve LOC. Players are more likely to experience headache, dizziness, confusion, disorientation and memory loss from a concussion. Coaches should become familiar with the signs and symptoms in Table 1 to better recognize potential concussions in their players. The presence of any of these symptoms warrants holding a player out of practice or a game.

A sports medicine professional is responsible for diagnosing, managing and making critical return-to-play decisions on behalf of an athlete that suffers a concussion; however, the “invisible” nature of this injury discussed above can make these responsibilities difficult. Unlike other injuries, detecting a concussion often relies on an athlete telling coaches, parents or sports medicine personnel that they are experiencing symptoms such as headaches or balance problems. Athletes may not tell anyone about their symptoms because they do not want to be removed from participation or do not realize that these symptoms may be signs of a concussion. In addition, social pressures also may prohibit athletes from disclosing their symptoms for fear of ridicule by their teammates or coaches. As a result, many soccer-related concussions go undetected.

Experts that study the effects of concussion recently have made recommendations for managing this injury. They urge a conservative approach toward every concussion, regardless of severity, and stress that concussed athletes be prohibited from re-entering competition regardless of their status on the sideline. Allowing an athlete to return to play before the brain is completely healed can place that athlete at an increased risk of another concussion, long-term symptoms, severe cognitive difficulties and, in rare cases, death. Coaches need to realize the dangers associated with returning an athlete to play too soon and should work with sports medicine professionals to keep players safe and avoid these potentially dangerous consequences.

A concussion can evolve in the days following injury. In addition to reported and observed symptoms, less overt mental changes can be readily tracked using a computerized neuropsychological test (e.g., ImPACT, CogSport). Computerized neuropsychological tests, which resemble simple video games and measure reaction time, memory and processing speed, compare pre- and post-concussion cognitive performance. This management tool is growing in popularity because of its cost effectiveness and ease of administration—most test licenses cost between $500 and $1,000 for a league or team. These tests provide a method of concussion management that is more reliable than self-reporting by athletes. It is recommended that whenever possible these concussion tests be used by soccer leagues or individual teams.

In general, recovery from concussion can take three to 14 days. Numerous factors may influence the length of recovery time from concussion. Studies have shown that a prior history of concussion can lead to longer recovery times and higher risk for another concussion, especially in younger athletes. In addition, females have been found to be at a higher risk of concussion and take longer to recover than males. Factors such as age, gender and history of concussion make managing this injury difficult. Concussion is unpredictable, and no two athletes will exhibit identical symptoms.

Coaches will want to know when their athletes will be ready to return to play. Athletes are considered to be recovered when they are symptom-free at rest and during exercise; however, coaches and sports medicine professionals must count on athletes being truthful in reporting their symptoms during the recovery period. Again, athletes may lie about their symptoms in order to return to play before they are ready. Returning an athlete too soon can have serious consequences if that athlete suffers another concussion before the first one heals completely.

Can an athlete that has sustained a concussion return to play in the same game when their symptoms have resolved? This can be a very complex issue because athletes lie about their symptoms and feel pressure to return to the contest. These decisions also are difficult because there is not only concern for the resolution of symptoms, but also the cognitive (or mental) recovery of the athlete.

A concussion also affects cognitive abilities such as reaction time, ability to think and respond and memory. Studies have shown that cognitive recovery can be delayed for up to 24 hours after the concussion has occurred. Lingering effects from a concussion can increase the risk of a player sustaining another concussion or making their existing injury worse if they return to play too soon. This could result in a player missing even more time because of the concussion. In rare instances, players who sustain a minor blow to the head while still symptomatic from an ongoing concussion could die from something called Second Impact Syndrome.

If players still have any symptoms or cognitive problems, they should not be allowed to return to play. As a general rule, “when in doubt, leave them out.” In other words, err on the side of the player’s safety.

In the past decade several companies (e.g., Full90, Kangaroo) have begun marketing protective headgear for soccer players. The purpose of protective headgear for soccer is to decrease the force of impact to the head from a ball, another player, ground or goalpost. Reducing these forces that are absorbed by the skull might, in theory, reduce the risk of concussion; however, there is debate surrounding the use of protective headgear in soccer. Some believe that protective headgear will provide a false sense of security, possibly encourage more risk-taking by players and possibly lead to the deterioration of heading skills. Others believe it is long overdue in the only sport where players purposely propel the ball with their heads.

This debate, along with manufacturer claims regarding the effectiveness of their products, has prompted researchers to begin to evaluate the effectiveness of these products. Thus far, the research findings on headgear effectiveness are mixed. Findings do suggest that headgear is useful in reducing lacerations and bruises to the head and part of the face; however, most studies suggest that wearing these products will not reduce the risk for a concussion. Recent research concluded that headgear was not effective in decreasing the forces associated with heading a soccer ball, but might be effective in reducing forces associated with head-to-head contact. Earlier reports have found headgear to be effective at higher speeds, but not effective at lower speeds that are more common in soccer. There are few studies that have evaluated the usefulness of protective headgear in soccer, and there is a definite need for more studies in this area. However, coaches that support wearing these protective devices should understand that no current protective headgear will prevent a concussion in soccer.

Concussion is an injury that coaches, parents and players should take seriously. It may be difficult for players to admit to their coaches or sports medicine staff that they have concussive symptoms (i.e., headaches) for fear of being removed from participation or ridicule from teammates and others. However, coaches should encourage athletes to be truthful about their injuries and support decisions made by their sports medicine staff members. Coaches also should become familiar with the signs and symptoms of concussion and should not allow a player who has a concussion return to the field in the same game or practice. It is important for coaches not to pressure athletes into returning to play before they are completely recovered – even for a championship game. In most instances these decisions will be made by sports medicine personnel; however, club and recreational coaches often will find themselves as the only person in a position to make a return-to-play decision on the field. Coaches should err on the side of caution. Players will be served best if coaches support them and keep them involved with team functions and activities when they are injured. A concussed athlete may feel withdrawn from the sport environment, and coaches are in an ideal position to make athletes feel that they are still part of the team even when they are injured. In summary, concussion can be a serious injury if mismanaged, but with proper education and precautions, concussed soccer players can experience a full recovery and return successfully to participation.

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Editor’s Note: This article originally appeared in the March-April 2009 issue of Soccer Journal (NSCAA).